APPENDIX 3
We have taken the following information from
an unpublished set of training notes drafted by POPAN for training
for the psychological therapies.
1. WHAT IS
PROFESSIONAL ABUSE?
In order to conceptualise abuse by health and
social care professionals, we must recognise that the professional
helping relationship is often one-to-one, involves trust and an
imbalance of power: one person is invested with the power to heal;
the structure of the relationship means he or she also has the
power to harm. Ethical frameworks and professional boundaries
exist to protect the client or patient, who is vulnerable, from
exploitation. Stereotyping and discriminatory attitudes towards
socially marginalized groups can be compounded in professional
relationships. Exploitation occurs when practitioners use formalised
helping relationships to put their own desire for sexual, physical,
emotional or financial gratification ahead of the needs of the
client.
1.2 How do practitioners get away with abuse?
Practitioners are often able to get away with
abuse because they:
— have access to privileged information
and resources;
— are trusted by clients;
— are believed to be skilled and knowledgeable
and not to be questioned;
— become someone on whom the client
is dependent; and
— work in a setting where their practice
goes unexamined.
1.3 Characteristics of Professional Abuse:
— may be sexual, financial, emotional,
physical, discriminatory;
— can be one-off, occasional or recurring;
— is on a continuum from mildly harmful
to grossly harmful;
— can occur in many different settings;
— may be planned and predatory, or
opportunistic;
— targets the most vulnerable; and
— many practitioners gradually slip
into abusive practices, starting with apparently minor boundary
violations.
POPAN helps those who have been abused by health
or social care professionals. The majority of the information
POPAN has is about therapists, doctors, nurses, psychologists
and complementary therapists. The most common types of abuse are
sexual and emotional. These frequently overlap.
1.4 What makes abuse more likely?
— predatory or manipulative practitioners;
— inexperienced, incompetent or careless
practitioners;
— prejudice and stereotyping, including
racist, sexist etc attitudes;
— temporary impairment in practitioners
eg intoxication, illness, mood disorders;
— harmful techniques or approaches;
and
— specific vulnerabilities in clients
or patients eg prior sexual abuse;
— practitioner's level of competence
does not meet client's needs;
— insufficient training, supervision
and support;
— inadequate staffing and high workloads;
and
— absence of culture of transparency;
— inadequate structures for accountability.
Additional reading: (see Recommended Reading
lists for details)
"The prevention of client abuse in psychotherapy"
by Nash and Blunden (1999).
"Exploitation in therapy and counselling:
a breach of professional standards" by Hetherington (2000).
2. WHO IS
AT RISK
OF ABUSING?
There is no satisfactory research in the UK
to answer this question; much of the theory and research is from
North America. POPAN collects data, but has no way of knowing
if this is representative of the helping professions or whether
any generalisations can be made from its data. It is nonetheless
interesting to note that 80% of alleged abusers are men.
Some studies show that abusers are often of
high status and well-qualified within their profession. They are
certainly more likely to get away with abusive practices—they
are less likely to be challenged, to be held to account, to seek
supervision, to be disbelieved if they deny impropriety, to accept
limits or sanctions, or to curb a wish to indulge in unconventional
behaviour. They may believe "ordinary rules" do not
apply to them. They may behave abusively out of arrogance and
unawareness, or they may be manipulative and predatory.
Other factors that increase practitioner risk
of abusing, which may be temporary or long-term, include:
— need to improve self-esteem through
clinical work;
— need to be liked or to be approved
of;
— social or work isolation, work stresses;
— confusing own needs with those of
client;
— seeing oneself as special, creative,
not bound by usual regulations;
— influence of male/female socialisation
practices;
— poor knowledge/self-awareness re
boundaries;
— personal history of boundary violation
eg childhood sexual abuse or rape;
— little or no skills re management
of sexual feelings towards patients; and
— sub-clinical/clinical psychiatric
disorder.
The attitudes of abusive practitioners tend
toward being either over-involved or excessively distant. Attitudes,
knowledge, and skill in handling difficult aspects of the process
of giving medical care (eg not reacting in a retaliatory or defensive
manner) are crucial: exploitation and harm are likely to occur
when practitioners do not deal properly with negative aspects
of clients' interactions.
North American research studies indicate psychiatrists,
psychologists and social workers have self-report figures of between
2% and 7% for sexual contact with clients. Surveys suggest that
anywhere from 33% to 80% of professionals who acknowledge sex
with a client state it was with more than one.
3. WHO IS
AT RISK
OF BEING
ABUSED?
3.1 Social disempowerment:
No-one is immune from the possibility of being
a victim of abuse by a health professional, but those groups of
people who are disempowered by society are likely to feel further
disempowered by the unequal relationship with a professional,
and this is often exploited by abusive practitioners, particularly
as socially marginalized individuals are less likely to be willing
to raise concerns, less likely to be heard and less likely to
be believed. So—there is greater vulnerability to abuse
amongst:
— users of mental health services;
— members of ethnic minority groups;
— people who are physically impaired
or intoxicated; and
— people who are physically dependent
on others.
3.2 Psychological vulnerability
There are also individuals who are psychologically
fragile and who may struggle with issues of dependence, abandonment,
over-idealisation and devaluation of others, feelings of emptiness,
and intense neediness, who may be very challenging for practitioners
to work with and who (through no fault of their own) then become
victims—as helpers get out of their depth, become over-involved
and violate boundaries.
3.3 Re-victimisation
Victims of sexual, physical or emotional abuse
in childhood tend to be re-victimised in later life (including
domestic violence, rape, prostitution and abuse by a professional).
Ways in which abuse in childhood may be linked to re-victimisation
may include:
— parentification/role reversal;
In particular, victims of childhood sexual abuse
may have little or no experience of consistent or appropriate
boundaries, on which to judge the behaviour of someone they are
expected to trust.
Recommended additional reading:
Article: To the point by Rosie Alexander
(1996)
Books: Herman (1994) Epstein (1994)
4. THE EFFECTS
OF PROFESSIONAL
ABUSE ON
VICTIMS
There is a continuum of abusive behaviour by
Health and Social Care Professionals, and effects will vary. Occasional
or minor boundary violations (such as self-disclosure about a
current personal problem) are likely to cause confusion for the
client and introduce ambiguity into the relationship. Practitioners
who are either too distant or too intrusive are likely to cause
at least discomfort, at worst long term emotional harm and distress.
Premeditated exploitative behaviour—emotional,
physical, financial or sexual—has serious and long-lasting
psychological effects on the client/patient. These include:
— ambivalence and confusion;
— isolation and emptiness;
— loss of self-esteem and loss of confidence;
— sense of humiliation or shame;
— self-harming behaviours (eg substance
abuse);
— extreme distress, including unresolved
grief;
— impaired ability to trust in any
relationships;
— symptoms of post-traumatic stress
disorder (PTSD);
— suicidal feelings and suicide attempts;
— inability to trust own judgement;
and
— anxiety and depression.
In addition, there is the vicious cycle of:
— failure to have the original problems
(for which help was sought) dealt with;
— worsening of the original problems;
and
— impaired ability to approach or trust
other health or social care professionals.
There are many parallels in the effects of professional
sexual abuse with the effects of childhood sexual abuse, and with
domestic violence and sexual crimes in general. Self-blame is
common. Victims may begin to rely on a range of defence mechanisms
to protect them from acknowledging the violation that has occurred.
In particular, it may be many years before they are able to recognise
what happened and/or to take steps to deal with it.
Violating boundaries in pursuit of sexual gratification
by Health and Social Care Professions at first results in mixed
messages. The practitioner breaks the therapeutic frame and starts
going down a "slippery slope":
— ambiguity, potential role reversal
is introduced to the relationship;
— patient starts to feel uneasy and
tense;
— a sense of "special relationship"
is introduced by the professional;
— previous boundary violation issues
for the patient may be triggered;
— the patient is invited to "test
the limits";
— at first the patient may experience
excitement/sense of extra nurturing or care;
— patient may be persuaded into believing
practitioner's wishes/actions are in the client's best interests;
and
— negative reactions are delayed or
blanked out.
4.2 Layers of psychological damage—the
particular effects of sexual abuse (summarised from Peterson,
1992)
— survivors develop "explanations"
for practitioner's behaviour;
— struggle with feeling baffled by
practitioner's true agenda, bewildered by professional's deceit,
confused by two realities;
— betrayal of trust threatens beliefs
with which they anchor themselves to the world;
— trusting seems dangerous;
— avoidance and withdrawal to protect
themselves;
— acknowledging helplessness is scary,
so go to great lengths to ward off the truth of their victimisation;
and
— but this leads to never-ending spiral
of self-condemnation.
4.3 Blocks to gaining validation
— shame and secrecy, plus invisibility
of psychological wounds, mean that clients question the validity
of their experiences;
— may get backlash from friends, family
or professionals; and
— may be inaccurately diagnosed as
borderline, paranoid, or having an anxiety disorder.
4.4 Obstacles to healing
— unavailability of appropriate therapists,
not able to afford private therapists, difficulty finding advocacy
and appropriate solicitor if going to court;
— feeling belittled, trivialised, blamed
during court or complaints process. Lack of support or even secondary
victimisation by friends and family;
— losses suffered during and after
the abuse—marriage, savings, job or career, house, health.;
— even with therapy, a persistent lack
of confidence, shame, self-blame and difficulty trusting their
judgement of people and situations; and
— feeling in limbo, unable to progress
with their lives, frequently re-traumatised during court or complaints
process.
There are likely to be profound destructive
effects on the family and others close to the abused client.
4.5 Effects of abuse on associate victims
— the damage caused by professional
sexual abuse is widespread;
— every victim/survivor is a partner,
wife, mother, daughter, son, brother, sister, friend, etc;
— these groups of people can be identified
as associate or secondary victims;
— many victims will have entered mental
health services at a time when there may already be some difficulties
in their ability to sustain their close relationships;
— many victims suffer PTSD and we know
that other situations which cause PTSD impact on loved ones also;
— associate victims often end up confused,
and are not helped to understand what has happened to their loved
one;
— most literature concentrates on examining
the relationship between the perpetrator and the victim but has
not recognised the wider context;
— if the victim has been made to feel
responsible for the abuse they may struggle to tell their partner
about what may be seen as an "affair";
— many victims will struggle to sustain
any intimate relationship after the abuse and this is particularly
difficult if the issue is not clearly understood;
— the victim may have originally been
seen with their partner for couple therapy in which case there
is a double betrayal;
— direct victims may not be able to
tell their children anything about the abuse but the children
may be witnessing and be confused by their mother's distress;
— if the victim is strong enough and
supported enough to disclose the abuse to family and/or friends
it can be a rich source of additional support; and
— daughters and sons can learn from
their parents' experience how to avoid abusive people themselves.
5. EFFECTS OF
PROFESSIONAL ABUSE
ON ABUSER'S
COLLEAGUES
There are likely to be profound "ripple
effects" on other members of teams or organisations when
an individual is known to have acted abusively. Regrettably, the
most frequent response by those in authority is to either brush
the incident under the carpet, or to "name and shame":
in either case the effect on colleagues, on the practitioner's
other clients and on the ethos of the organisation is not properly
addressed.
Common reactions are:
— disbelief and/or anger;
— polarisation of attitudes: usually
either protective or accusatory;
— splitting (in teams and groups of
colleagues);
— fear of being "tainted"
or "guilty by association";
— identification; "it could have
been me";
— recrimination and guilt for not having
prevented it;
— reduced self-efficacy; demoralisation
Recommended additional reading:
Books:
Fortune (1989)
Sands (2000)
Penfold (1999)
Pope (1994)
Articles: Disch and Avery (2000); Ward (1993)
6. RAISING CONCERNS
AND BEING
HEARD
6.1 Difficulties in raising concerns and being
heard for victims
— one of the effects of being abused
is feeling too ashamed and traumatised to talk about it;
— only 1/5 of those who contact POPAN
about abuse choose to raise it with the abuser's employer or professional
organisation/make a complaint;
— the vulnerability of clients and
their dependence on practitioners, or fantasies about their "specialness",
may prevent clients leaving abusive relationships;
— many clients have no experience of
being heard/taken seriously if they have been mistreated;
— many clients do not know correct
procedures, or the procedures are inaccessible or inadequate;
and
— many clients sense "something
is wrong" but do not themselves identify it as abuse or exploitation.
6.2 Obstacles for other practitioners raising
concerns
The health care professional's concerns may
be about a practitioner who is his/her colleague and/or friend.
His/her concerns may be about a practitioner
on whom he/she is indirectly financially dependent, eg an employer
or a person who makes referrals.
The person to whom concerns should be reported
— may be part of the abusive situation;
— may not take the practitioner's concerns
seriously; and
— may not believe the practitioner.
The health professional's concerns may be about
something, which others appear to find acceptable/normal.
The professional may fear being disliked, ostracised,
criticised or condemned.
The practitioner may believe that she/he must
not report concerns without being 100% sure of her/his facts.
The professional may not know what the correct
procedures are.
6.3 Suggestions For Encouraging The Raising
Of Concerns
— change the language used: eg "raising
concerns about professional behaviour" vs. "complaining";
"alerter" vs. "whistleblower"; "professional
conduct committee" vs. "complaints board".
— change the ethos in service delivery
organisations and professional organisations: eg health and safety
laws apply to all practitioners—raise awareness of the need
to have a psychologically safe environment;
— provide clients and patients with
written information about how to recognise practitioner behaviour
that may be cause for concern;
— ensure consistent, clear guidance
on raising concerns in a safe and effective way;
— individual practitioners should model
a "zero tolerance" attitude to boundary violations and
client exploitation, to encourage this in others;
— supervisors, managers and others
should indicate that discussing one's own mistakes or boundary
crossings is appropriate in a "learning culture"; and
— draw on other organisations' experience
on providing information about "raising concerns" (eg
booklets produced by the GMC and NMC).
7. COMPLAINTS
All NHS Trusts are required to have clear and
well-publicised complaints procedures.
A good complaints procedure properly carried
out is a vital part of keeping patients safe from abusive professionals.
The formality of complaints procedures is meant to ensure fairness,
neutrality, distance and an emphasis on the process, not on personalities
However, there is much difficulty regarding
"evidence" in a complaints hearing: unlike a criminal
court, the judgement is normally made "on the balance of
probabilities" rather than "beyond reasonable doubt"
and a board or panel will primarily base this on the accounts
given by the practitioner and by the client. Some bodies, however,
such as the GMC or Nursing and Midwifery Council, do use a criminal
standard of proof. An abused client will find it particularly
difficult to trust a panel of people if she believes them to be
colleagues of the abusive practitioner. It is crucial to have
an appropriate number of lay people involved in complaints procedures.
A frequently asked question is "Don't clients
often make up allegations?" Research in North America and
in POPAN's experience shows that this is a fairly rare occurrence.
It is essential that all allegations are properly dealt with,
as occurs with child abuse. There may of course be misunderstandings
or less serious boundary violations, which are perceived by clients
as distressing and harmful, which are not best served by formal
complaints procedures. Individual doctors and practice managers
should ensure clients know about appropriate ways of having these
concerns attended to, if necessary involving a neutral third party.
7.1 What is the Public Function of a Complaints
Procedure?
— alerts appropriate people to others'
dangerous practices;
— maintains standards in a professional
group by ensuring unethical practitioners are excluded;
— demonstrates accountability and transparency
by being thorough, well-publicised and properly followed;
— enables clients who have had serious
concerns to have these redressed through appropriate means;
— enables individual practitioners
to take responsibility for malpractice or misconduct;
— demonstrates that sanctions against
practitioners can be effective; and
— provides feedback to the organisation,
from which all members can learn.
7.2 What is the Function of a Complaints Procedure
for the Survivor of Abuse?
— having their story heard by someone
in authority;
— stopping it happening to others;
— preventing the practitioner from
continuing to see clients;
— to move on from anger, betrayal and
hurt; and
— to feel they are regaining some personal
power.
7.3 What survivors want from a complaints
procedure
— opportunity for third party consultation,
and/or mediation, prior to formal complaint hearing;
— prompt responses to queries and letters,
clear deadlines for all parties;
— to be kept fully informed of the
process;
— a procedure that is clear, well thought-through
and thorough;
— terminology to be free of pathologising
language and technical jargon;
— sensitivity to client's needs during
proceedings (eg needing breaks);
— recognition of the likelihood of
the client having lower income and fewer resources than the practitioner
(eg less likely to have professional or legal representation);
— clarity about confidentiality and
respect for privacy;
— recognise unequal power relationship;
— complainant to be allowed representation;
— recognition of the possibility that
the practitioner may lie;
— questions to be put through a chairperson:
practitioner should not face or directly confront client;
— recognition that complainants need
"closure", eg being told what sanctions have been imposed
on a practitioner; and
— the need for those responsible to
"apologise, not pathologise".
Recommended additional reading:
Articles:
Pilgrim and Guinan (1999)
Stokes (1991)
Books:
Casemore (2001)
Jenkins (2002)
Palmer Barnes (1998)
Copyright POPAN 2003
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